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Surgical Remediation for Symptomatic or Anatomic Failure After TIF (Transoral Incisionless Fundoplication)
Ruchir Puri^*, Steven P. Bowers, C. Daniel Smith
Surgery, Mayo Clinic, Florida, Jacksonville, FL

Background: TIF (Transoral Incisionless Fundoplication) is a minimally invasive technique for the management of gastroesophageal reflux disease (GERD). The long-term outcomes of this procedure are unknown and there are few reports of surgical remediation for symptomatic or anatomic failure after TIF. Methods: Six patients with intractable foregut symptoms after TIF underwent surgical remediation between June 2011 and September 2013. Data were obtained by retrospective chart review. Nature of symptoms, anatomic abnormality, surgical technique and outcomes were analyzed. Results: The patients (4 female and 2 males; mean age 56.8 years) presented after a median of 19 months following TIF. Presenting symptoms were persistent reflux (n=4) and severe dysphagia (n=2). Contrast esophagram and EGD characterized two patients as having normal post-TIF anatomy and four as having anatomic failure [hiatal hernia (n=2), multiple esophageal diverticula (n=1) and long distal esophageal stenosis believed due to chronic microperforation (n=1)]. All patients underwent a laparoscopic takedown of the prior endoscopic fundoplication and removal of all fasteners. Four patients underwent Nissen fundoplication, two with hiatal hernia repair. One patient underwent stapled resection of multiple esophageal diverticula, each found to have a fastener at its apex. One patient with long esophageal stricture required myotomy of the thickened and stenotic esophageal wall. Mean operative time was 170 minutes and mean length of stay 4.5 days (range 2-15 days). There were no major perioperative complications and no mortality. The patient with esophageal stenosis required a dilatation at three months post operatively. At follow-up, three patients have persistent complaints of chest pain (n=1) and dysphagia (n=2). Conclusion: Anatomic distortion of the distal esophagus after TIF can be significant, making remedial operation complex and technically challenging. Long term benefits of this procedure need to be assessed closely in light of these failures.

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